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Forefoot Varus Predicts Subtalar Hyperpronation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Dec 17, 2014.

  1. Jeff Root

    Jeff Root Well-Known Member

    There is some clinical evidence to support my statement above. On occasion, a patient with forefoot varus correction will complain about pressure/discomfort near the anterior medical aspect of the device or anterior, lateral discomfort with forefoot valgus correction. This pressure can be much more noticeable after heel lift, as the patient attempts push off. When this occurs and if can't be tolerated by the patient, the lab has to reduce the varus or valgus correction or may add a varus or valgus extension to the top cover to further support the plane of the forefoot. It there wasn't a varus or valgus reaction force resulting from the orthotic correction after heel lift, then the patient wouldn't be complaining about discomfort.

    Jeff
     
  2. I also disagree with that, not you but the statement

    CNS will change Gait cycles weight bearing and non weightbearing due to changes such as surface stiffiness, so I have always thought the same thing re devices and posts etc
     
  3. drhunt1

    drhunt1 Well-Known Member

    Eric-it appears from my perspective that you're trying to drive square pegs into round holes. For instance, I was referring to a structural hallux limitus creating dorsal bunions. In the following article from 2009, take a look at the second jpeg. It is a lateral WB plain film radiograph that the author identifies as a functional hallux limitus. I disagree.

    http://lermagazine.com/article/functional-hallux-limitus-diagnosis-and-treatment


    That is a forefoot varus deformity with a huge MPE. Look at the lack of overlap between mets 5 and 4...it's almost like you're looking at each individual metatarsal on oblique view. I guess the fact that there's no dorsal exostoses, in his mind at least, means that it's defined as a functional HL. I suggest that there might be other circumstances, (ie., hypermobility) that doesn't jam that joint. We don't know how old of a patient that X-Ray is taken of, which would also enter into the equation. Honestly, I cannot remember a patient that presented with a dorsal bunion that did not also present with a MPE deformity, except in the case of trauma.

    But let's take his, (and your), suggestion that the windlass mechanism is all encompassing...the effect even including HAV bunions. OK...that mechanism is a sagittal plane restriction. Why is it that we never see hallux varus deformities as a result of this same mechanism? We don't, even with patients that present with very rounded, unstable 1st MPJ's. We only see the transverse plane results of MPV and HAV when we look at X-Rays and at people's feet. There simply has to be another factor that enters into the equation...some slight adductory force on the first met that results in long standing osseous/joint changes at the head and base. Considering the FHL is responsible for 75% of the propulsive power of the forefoot, and is as big in diameter as a pencil...that's my guess. When the heel comes off the ground as the patient enters into forefoot loading to begin the propulsive phase of gait, if there is a collapsing of the MTJ/medial column, then the 1st met is unstable. Having its own ROM, the 1st met dorsiflexes and slightly adducts by patient weight vs. GRF. The FHL tendon then is ever so slightly bowstrung at first....becoming even more so as time accelerates the changes to the 1st met base/medial cuneiform jt in an equally adductory manner. Again...simplistic...but you get my idea...I think.

    Podiatry should have serial plain film radiographic studies published on ALL of these long term problems...but we don't. As I wrote early in this thread, we don't even have serial X-Rays of the developing foot....and it's a shame.
     
  4. Jeff Root

    Jeff Root Well-Known Member

    Matt,

    As Jim Clough stated in the article, the difference between functional hallux limitus (FHL) and structural hallux limitus (SHL) is based on comparing the open chane range of dorsiflexion of the hallux to the closed chain range of dorsiflexion of the hallux. The presence of FHL must ultimately be assessed during gait.

    What I find interesting in the article, which I coincidentally had partially read earlier the same day before you posted it, is that Craig Payne et al. identified FHL in 53 of 86 asymptomatic feet. If 62 percent of these subjects demonstrate FHL with no symptoms, then even if your full length varus extension creates some degree of FHL, the question remains, will the varus wedge create symptoms or harm?

    If your varus wedge creates some degree of FHL, and we do not know that it necessarily will, and if you're are able to reduce or eliminate the patient's chief complaint (pain), then one could argue that the patient might be better off with the potential for hallux limitus in exchange for a reduction in current symptoms, especially since hallux limitus is often asymptomatic. Would you agree?

    Jeff
     
  5. I think we can agree that a forefoot varus wedge should increase the dorsiflexion moment acting on the medial metatarsal rays- which takes us back to the start of the thread:

    And,
    So, is a forefoot varus deformity a problem or not? ...your choice.
     
  6. Jeff Root

    Jeff Root Well-Known Member

    Yes, when the forefoot varus deformity is responsible for a retrograde eversion moment at the STJ causing excessive STJ pronation during gait.

    Jeff
     
  7. So, you are happy to increase the degree of forefoot varus deformity through the use of forefoot varus wedging then, Jeff?

    Actually, your response opens a whole new can of worms: is "excessive STJ pronation during gait" (whatever that is supposed to mean) a problem? What does the latest meta-analyses tell us?

    Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review
    Geoffrey J Dowling, George S Murley, Shannon E Munteanu, Melinda M Franettovich Smith, Bradley S Neal, Ian B Griffiths, Christian Barton and Natalie J Collins
    Journal of Foot and Ankle Research 2014, 7:53 doi:10.1186/s13047-014-0053-6[/QUOTE]

    A quick tune while we ponder whether movement causes injury, or whether the levels of stress within the tissues cause injury: https://www.youtube.com/watch?v=WD8ASzGVs3g 5 beats in the bar; interesting yet awkward.
     
  8. Jeff Root

    Jeff Root Well-Known Member

    Simon, actually as I have stated many times before on the Podiatry Mailbase and the Podiatry Arena, I have seen, because we bisect the heel and measure ff to rf angles in casts, that an orthosis with intrinsic ff varus correction will often actually reduce the inverted angle of the forefoot inversion in the foot (if measuring the foot) and in subsequent casts of the foot. Whether this is a reduction in ff varus or ff supinatus is anyone's guess, but it does happen. If you search the archives you will find that I described a very characteristic Rohadur orthotic breakage pattern associated with the resulting decrease in the inverted relationship of the forefoot. So no, I would not be happy increasing forefoot varus deformity and I'm glad that this hasn't been the case. Another good reason why measuring ff to rf is important.

    Excessive stj supination or pronation can be a problem. And insufficient stj motion can also be a problem.

    Jeff
     
  9. So, when you apply forefoot varus posting, you somehow break Wolff's and Davis's Laws and as you do, you also re-write material science. Come on Jeff, the answer is simple... Do forefoot varus posts increase the dorsiflexion moment on the medial metatarsals or not? If they don't, then how do they work?

    And we have data to support your contention of course, Jeff? I have seen, because we bisect the heel and measure the forefoot to rearfoot alignment that the moon is really a balloon. Moreover, let's assume that you are right and the forefoot varus decreases in the cast- how do you know that this is not due to variation/ poor reliability in the casting position/ heel bisection? Of course, you've never seen a forefoot varus increase in serial casts, ever, ever?
    How many degrees is "excessive"? How many degrees is "insufficient"?
     
  10. Jeff Root

    Jeff Root Well-Known Member

    Simon,

    I can only tell you what I have observed and measured in my own lab experience and there is a pattern to it. On rare occasion I have seen the angle of varus increase with forefoot varus posting but the pattern is overwhelming in the direction of a reduction in the inverted angle of the forefoot to the rearfoot. I'm convinced the reduction in ff inversion angle is a result of soft tissue adaptation.

    I became aware of this pattern when Root Lab would always record the ff to rf angle of the cast on the Rx form. One copy was stored at the lab and the other was returned to the doctor so they could see what the lab was correcting in the positive cast. If an orthosis was reported to have fractured, we would compare the new cast to the ff measurements on file and if there was a large ff angle, we would request they recast rather than repress the device over the original cast. In fact, we had a number of doctors who would automatically recast for comparison purposes and we would only use the new cast if we could document a reduction in the inverted angle of the forefoot.

    Likewise, we would also see decreases in the angle of ff eversion, most often associated with a decrease in the degree of plantar flexion of 1st ray. This occurred with valgus posted orthoses. We did see some increases forefoot eversion angle associated with an increase in plantar flexion of the 1st ray, but again, the pattern was significantly tilted in the direction of reducing the everted forefoot "deformity".

    We no longer automatically record ff to rf measurements although the box it is still on our Rx and we still do so on request or by customer default. Since we use so little acrylic plastic as compared to composites and polypropylene, we don't see these breakage patterns so the reduction in ff angle isn't identified as often these days.

    Jeff
     
  11. Jeff Root

    Jeff Root Well-Known Member

    Obviously that is a clinical judgment just like medial or lateral stj axis location drawn on the plantar surface of the foot and its relationship to function/pathology is a clinical judgment.

    Jeff
     
  12. Jeff, do you think your "observation's" are theoretically plausible and biologically coherent, given what we know about the biomechanical effects of forefoot varus wedging and the tissues responses to loading? To the casual observer, they should not be. What magic is occurring here? Can you think of any reasons why the forefoot to rearfoot alignment might have changed in the measurements from the cast given what we know about the reliability of non-weightbearing casting?

    Can you think of any other reasons why the acrylic might have broken?
     
  13. But we weren't talking about STJ axis position, let's try and stick to the moot point (we can discuss STJ axial position later if you still wish) rather you stated that:
    Now, "excessive" is a "clinical judgement". Can we agree then that there will be variation between individuals, and that this variation is normal, that the degree of motion at a joint does not predict the stress in the restraining tissues? Or, by "clinical judgement" do you think the clinician should pick a number of degrees of pronation and anyone who exceeds that number should be classified as "excessive"?
     
  14. I'll just quickly jot this down before I have some dinner, family time, then bed. It's a pretty simple analysis I lead y'all to.

    Let us explore a reduction in the measured forefoot varus/ supinitus (call it what you will) in response to forefoot varus posted foot orthoses which Jeff claims he has seen.

    In order for the supinatus to reduce, there must be a reduction in the dorsiflexion / inversion moment acting upon the medial metatarsals and/ or a decrease in the rearfoot eversion/ plantarflexion moment occurring in response to the foot orthoses- both are possible. A forefoot varus post will increase the dorsiflexion/ inversion moment acting on the medial metatarsals. But, it is possible that the net forefoot dorsiflexion/ inversion moment on the forefoot might be reduced via the varus rearfoot posting and medial longitudinal arch section of an orthoses shell, even in the presence of a forefoot varus post. Yet since the forefoot varus post will act to reduce this net effect, we have to ask the question- why bother with the forefoot varus post since this is just working against our remodelling?
     
  15. efuller

    efuller MVP


    Square peg round holes???. Matt, I think you missed that the foot in that radiograph is quite supinated. (post break in cyma line, lateral process of talus is fairly high up the posterior facet of the talus, the posterior process of talus is overhanging the posterior aspect of the calcaneal facet of the STJ.) This foot is being held supinated by something. Which would create the minimal overlap that you noticed. My guess is that the foot was held supinated so that the viewers could see the lack of pathology at the first met head.



    He defined functional hallux limitus at the start of the article. I would assume that he found minimal motion upon weight bearing. Met primus elevatus is all where you draw the line. If all you have is a hammer everything looks like a nail.



    You do see hallux varus in unshod populations. (I've seen pictures, but unfortunately don't have a cite.) In shoes, the shoe will apply a force to the tibial side of the hallux to push the hallux toward the second. This will lower the incidence of hallux varus.

    What's propulsive power of the forefoot? Where'd you get 75%? Hicks measured the windlass as several times more powerful than any muscle. I'm agreeing with your mechanism. When there is bowstringing there is a force couple created. The same mechanism works for the more powerful windlass mechanism.

    Eric
     
  16. Jeff Root

    Jeff Root Well-Known Member

    Simon,

    I agree with your reasoning here on the mechanism that could be responsible for the reduction in the inverted position of the forefoot. And I agree that we really do not know if is necessary to have the forefoot as inverted in the casting process to get the same result of a reduction in the angle of forefoot inversion with the orthosis because this has never been tested to the best of my knowledge. In fact, it is perhaps possible that we should be plantarflexing the medial column to reduce the angle of inverted ff conditions and dorsiflexing it to reduce the angle of everted forefoot conditions. Unfortunately we don't know how important the varus or valgus support (correction) actually is. It may be that it is beneficial in some cases, based on the morphology and function of the foot but not in other cases. We just don't know. But until it is tested and I have good reason to do something differently, I will continue to use the techniques that I have been using all these years.

    There has already been some change in how some practitioners cast the foot. It has become increasingly popular to "cast out ff supinatus" (this is a poor terminology, I prefer the terms "reduce the angel of ff inversion" or "plantarflex the medial column" since the patient doesn't necessarily have ff supinatus in every case where this technique is performed). Drs. Root and Weed did advocate reducing the angle of 1st met plantarflexion in cases of ligamentous laxity if the 1st ray tended to plantarflex during supine, suspension casting. They and other Root Lab customers also did this if they felt there was too much valgus to support, or they would have the lab shave down the positive cast under the 1st or 1st and 2nd mets to reduce the angle of ff eversion. We still do this periodically for some customers. So there is some history of altering the ff to rf relationship and not always correcting the entire angle of ff position present in the positive cast. We just need better guidelines for this practice.

    Jeff
     
  17. drhunt1

    drhunt1 Well-Known Member

    Eric-you're the one making the claim that the windless motion is responsible for ALL bunions...thus my quote. I can't remember where/when I read that the FHL is 75% of the propulsive power from the forefoot, but it's a pretty safe bet, considering the size of the tendon in comparison to the FDL tendon(s), the pressure line of the plantar aspect of the foot and the ramifications of amputating a hallux and following these patients post op for extended periods of time.

    So now the assumption is that the jpeg in that article represents a supinated foot, held in that position for discussion sake? OK...I saw the posterior break in the Cyma line, but there's other reasons why that could be beyond the author "fudging" on the WB status of that patient. Nonetheless, my assertion still stands that rarely have I seen a patient with a dorsal bunion that didn't present with a MPE deformity as well.

    You state that hallux varus DOES exist, but we don't see it because of shoe gear. OK...I'm not opposed to that, but it does take another 'leap of faith' in order to accept that for all patient groups. Occam's razor?

    Jeff brings up a good point about my forefoot extensions not necessarily causing dorsal bunions or pain in that joint. I'm just not buying the train of thought that by doing so, I'm actually increasing the forefoot varus deformity by stretching the soft tissue. I will wait to see the results, long term, of my approach.
     
  18. Jeff Root

    Jeff Root Well-Known Member

    Simon,

    I think adult acquired flatfoot provides a good demonstration of forefoot supinatus and just how quickly ff supinatus can develop. I suspect that the majority of the acquired inverted angle of the plane of the forefoot results from dorsiflexion of the medial column at the talonavicular joint (ie. talar plantarflexion/navicular dorsiflexion) and develops into a supinatus contracture due to stretching of the ligaments and other supportive tissues of the medial longitudinal arch.

    When the forefoot is in contact with the supporting surface and when the rearfoot pronates severely as it does in the case of adult acquired flatfoot, it creates relative inversion of the forefoot to the rearfoot. In other words, the talus adducts and plantarflexes relative to the navicular, which creates relative dorsiflexion of the navicular and the distal segment. This relative dorsiflexion of the distal segment results in relative inversion of the forefoot. So in theory, if we can resist talar adduction and plantarflexion by applying an orthotic reaction force plantar to the head of the talus and the navicular, and if in so doing we prevent or greatly reduce the rearfoot pronation moment, then we may not need to incorporate as much if any varus support at the distal aspect of the orthosis.

    Basically intrinsic or extrinsic varus support acts to accentuate the longitudinal, medial arch of the orthotic shell. Since the orthotic doesn't extend under the metatarsal heads, it is also possible that the orthotic creates a slight plantarflexion moment of the 1st ray by pressing up more in the area of the 1st metcuneiform joint and the talonavicular joint than it does at the distal aspect ot the 1st met and the 1st mpj. I have never really considered this before now, but I suppose it is possible.

    Jeff
     
  19. Jeff, I think we are pretty much on the same page here. It's obvious that if we increase the forefoot dorsiflexion/ inversion moment with a forefoot varus post then an increase in forefoot inversion/ decrease in forefoot eversion should ensue due to tissue adaptation and plastic deformation. By defintion this should result in a relative increase in the rearfoot plantarflexion/ eversion- not necessarilly what you want to do in a symptomatic flatfoot (for sure it may help in the short term, but in the longer term?) Interesting to note that Sayle-Creer recognised that rearfoot varus wedging in combination with forefoot valgus wedging was an effective therapy for flat-foot back in the 1930's “By wedging the inner border of the heel and thus inverting it, the tibials are relieved. By wedging the outer side of the sole, the foot is everted and the strain on the peroneus longus is removed. Clinical practice shows that the degree of wedging must be determined for each individual case.”; love that quote, such a combination should provide the greatest potential to reduce forefoot supinatus. I do use forefoot varus posts and forefoot varus wedging extended full-length on occasions, yet I do it with caution and utilise it predominantly in orthoses which the patient will only ever run in (less hallux dorsiflexion needed for running than walking), for example, medial tibial stress syndrome in which I am attempting to reduce the frontal plane bending moment within the tibia.

    I think the acryic fractures you observed were more likely due to the increased magnitude in cyclic loading due to the non-linear increase in stiffness of the medial metarsals with increasing dorsiflexion induced by the forefoot varus post. I think this, in combination with material fatigue and the stress-riser induced by the post itself, are far more likely to be the cause of the fractured acrylic shells than it being due to reductions in the forefoot to rearfoot inversion angle.

    My best friend when studying for my PhD was completing his PhD in material science, specifically in fracture mechanics. If I get chance, I'll give him a call.

    Now, "excessive pronation"?
     
  20. efuller

    efuller MVP

    Then wouldn't you want to shape the shell so that it's highest point is at the navicular and you would want to fill, in the cast, beneath the metatarsal and cuneiform. This is different than the classic Root forefoot varus intrinsic post where there is almost no fill beneath the distal shaft of the first met head.

    In our earlier discussions on this thread you were talking about how the metatarsal would be supported off of the ground by the forefoot varus post that ended behind the metatarsal heads. (You also mentioned the use of first ray cut outs and narrow shells to allow ray plantar flexion. The use of the these modifications would seem hinder the support of a forefoot varus.) I think Simon made some points along these lines already.

    Eric
     
  21. Jeff Root

    Jeff Root Well-Known Member

    Eric,

    In my experience, if you make the highest point of the orthotic shell in the navicular area, the device tends to become less comfortable or uncomfortable for the patient. And this is especially true for individuals with moderate to severe adult acquired flatfoot. We sometimes have to accommodate the navicular in order to reduce orthotic reaction force in this area with these types of feet. In most feet, the medial longitudinal arch of the positive cast has a fairly regular arch shape in the sagittal plane. If you increase pressure in the talonavicular area by lowering the apex of the arch that occurs anterior to the talonavicular area, it can become uncomfortable. This is especially true when the navicular or the talar head and the navicular are more prominent medially and plantarly. And these are the feet that have the most compromised arch and who in theory, need more support. But because the integrity of the arch has failed to the degree that it has, these patients have a more difficult time tolerating posterior, medial arch pressure. This is because the osseous structure collapses more under load, and as a result, it increases pressure on the orthotic in this area because the cast was taken in a non-weightbearing condition. If we were to use a partial weightbearing cast, there would be even less orthotic reaction force in this area because of the arch would collapse under load, resulting in an even lower arched device and potentially too little force in this area.

    You sometimes see this same kind if problem (talonavicular area discomfort) with the Blake type orthosis because the medial arch is filled in more than with the Root type cast modification and as a result, the talonavicular area receives more orthotic reaction force due to the elevated medial heel/navicular area where it transitions into the heavily filled medial arch.

    Jeff
     
  22. efuller

    efuller MVP

    You said where you don't want the apex of the arch, but you didn't say where you would put the apex. (you did say regular arch shape, but I don't know what your regular arch shape is.)


    Both halves of Jeff's comment are quite dependent on the amount of arch fill. Blake in one of his articles mentions that inverting the cast will raise the medial arch height and that fill should be added to create a normal arch height orthotic. If one puts minimal fill in a neutral position cast for adult aquired flat foot then yes I would also expect irritation in the talar head, navicular area. Jeff, it appears that we are in agreement here. I will measure the arch height of the patient when standing and a little bit of force applied to the arch and I rarely get medial arch irritation. However, this is getting away from the idea that casting in neutral position was important. The orthotic works because force is applied to the arch in a comfortable manner and not because the foot was casted in neutral position and the neutral position shape was vitally important.

    Eric
     
  23. Jeff Root

    Jeff Root Well-Known Member

    I would put the apex in the same location as it occurs in the non-weightbearing cast of the foot. If we use less arch filler or more arch filler the apex will still be in the same location, just higher or lower from the supporting surface than it would be with a standard arch fill. If we want more reaction force in the talonavicular area we invert the cast or use a medial heel skive, or both, possibly in conjunction with reduced arch fill.



    Eric, how do you cast the foot? Do you use a non-weightbearing, a semi-weightbearing or a weightbearng casting technique? As for the Blake orthotic arch height, we have the same goal as Rich. However, the forefoot is not corrected to the same degree of ff varus or valgus in the cast, so the contour of the Blake device is different that a Root type Functional Orthotic in the heel area and in the forefoot. And these devices routinely have a plantar fascia accommodation, so it is my opinion that the Blake devices I see tend to have a lower medial arch than Root type devices.

    Jeff
     
  24. Jeff Root

    Jeff Root Well-Known Member

    Eric, did you see my question in my previous post? How do you cast the foot?

    Thanks,
    Jeff
     
  25. efuller

    efuller MVP

    Sorry Jeff. I did see and meant to respond, but other things got in the way.

    I cast the foot non weight bearing with the STJ somewhat supinated from the maximally pronated position. I will will put some load that will tend to dorsiflex and abduct the cuboid on the calcaneus. I will dorsiflex or plantar flex the first ray while casting depending on what I see on exam and what I want the finished shell to look like. Most of the time I will work around the forefoot to rearfoot relationship that ends up in the cast. I can do this because I make my own orthoses. Fore example if I decide that I want 3mm of forefoot valgus intrinsic post and 2mm of medial heel skive and I create a cast that has 3 degrees of forefoot varus, I will add the extrinsic post modification and then shape the heel by adding plaster plantarly and laterally and by shaving plaster medially until I get the shape that a 2mm medial heel skive should look like.

    Sometimes I will use Semi weight bearing casts. I had one patient with one of the worst PT dysfunction feet that I have ever seen. (He said the additional slope in his bathtub was unbearable when he stood in it barefoot.) It was too hard to get the arch shape right in the non weight bearing cast. I added a lot of medial heel skive to the semi weight bearing cast and made him a device that he doesn't ever leave at home.

    Eric
     
  26. Jeff Root

    Jeff Root Well-Known Member

    Here is a follow-up to the post above using the same subject. The first photo is his RCSP in his angle and base of gait and the second photo is with his Root Type Functional Orthoses under his feet. The third photo is of his medial arch with him in relaxed stance in his angle and base of gait and the fourth is with his orthosis under his foot. There is a significant difference in the frontal plane position of his rearfoot (calcaneal bisection), his MLA height and also in the transverse plane position of his tibia (less internal leg rotation with orthoses on). This demonstrates how graphic changes in the osseous position of the foot can be easily seen in some subjects. These devices are reported to be extremely comfortable and he states that his ankles "feel normal now".

    Jeff
     

    Attached Files:

    Last edited by a moderator: Sep 22, 2016
  27. drhunt1

    drhunt1 Well-Known Member

    Jeff-thanks for the videos...a picture, (or video), is worth a LOT more than a thousand words! I would suggest that in Adam's case, his forefoot deformity is the problem...it forces the rear foot into significant eversion in order to compensate. If one visualizes a plane the would represent the ground and then places that plane up to the forefoot, one can see the disparity of the medial column. Further, when you're forcibly dorsiflexing the forefoot, one can see that there's no change to the mets 1-3, but you're dorsiflexing the lateral column.
     
  28. Dananberg

    Dananberg Active Member

    Jeff,

    Thanks for taking the time to do this video and static photos.

    In the side views, there is clearly an equinus component to the stance position, and the orthotic seems to provide a heel lift which reduces the arch lowering compensation. The limited ROM in midfoot inversion and eversion (along with the ankle equinus) is very manageable via manipulation. Believing that this "is the patient's motion" is a big mistake. Once adequate joint motion is restored (and this can be in a single visit), you need far less posting than otherwise would appear necessary. I really don't know how I would treat patients without manipulation as the primary form of care. Manipulation should precede casting as the foot shape is so different post manipulation, that devices formed prior to this often are far less effective than after this type of care.

    Howard
     
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